ATTACH 4 - Past Performance Questionnaire.pdf

Middle Kyle Admin Site Water System Solicitation No. AG-0261-S-12-0009 Attachment 4

SOURCE SELECTION SENSITIVE WHEN COMPLETED

**NOT TO BE RELEASED OUTSIDE GOVERNMENT CHANNELS**

PAST PERFORMANCE QUESTIONNAIRE

US Department of Agriculture, US Forest Service, Region 4 – Humboldt-Toiyabe NF, Las Vegas, NV is considering the firm listed below. Your comments would be appreciated regarding this firm’s past performance.

Past Performance Information:

Name and Address of Firm Being Evaluated: _____________________________________________

Contract No.:________________________ Type of Contract:_______________________________ Project Title:_________________________ Date of Award:_______________________ Completion Date:_______________________________ Location:____________________________ Initial Amount:_______________________ Final Amount:__________________________________ Description:____________________________________________________________________________________

Evaluator: (The following information will assist in the analysis of the data)

Name of Evaluator:__________________________________________________________ Company/Agency Name:______________________________________________________ Address:___________________________________________________________________ Phone Number:_____________________________________________________________ Email Address:______________________________________________________________ Position Held or Function in Relation to Project:

Rating: If the rating is “Unacceptable”, please provide additional information in the appropriate block or in the remarks section of this form.

“O” Outstanding Performance greatly exceeded the contract requirements.

“G” Good Performance exceeded the contract requirements.

“A” Acceptable Performance met the contract requirements.

“M” Marginal Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory.

“U” Unacceptable Performance was poor and/or did not satisfy contract requirements.

Please circle the appropriate rating and provide any supporting information for the following:

1 The relationship between the firm and client’s/customer’s contract team: O G A M U N/A 2 The firm’s management and coordination of subcontractors/consultants: O G A M U N/A

3 Overall corporate management, integrity, reasonableness and cooperative conduct:

O G A M U N/A

4 Timeliness and quality of reports, deliverables, and other required submittals and documents:

O G A M U N/A

5 The firm’s business integrity: O G A M U N/A 6 Responsiveness to client/customer’s requirements: O G A M U N/A 7 Ability to control costs and provide the required work at a reasonable total price: O G A M U N/A 8 Contract Compliance: O G A M U N/A 9 Contract Management: O G A M U N/A 10 Compliance with safety standards and/or number of safety related incidents, code compliance, as applicable:

O G A M U N/A

11 Performance of Public Relations related to construction: O G A M U N/A 12 Quality Control Procedures: O G A M U N/A 13 Construction and installation of water systems including lines, valves and other appurtenances:

O G A M U N/A

14 Construction and installation of water storage tanks: O G A M U N/A 15 Installation of electrical systems: O G A M U N/A 16 Have any cure notices, show cause letters, letter of reprimand, suspension of payment, or termination been issued? If yes please explain:

Yes No

17 Would you award another contract to the firm being evaluated: If no, please explain:

18 Was the customer satisfied with the end product? If no, please explain:

19 Has the firm being evaluated been provided an opportunity to discuss or respond to any negative comments or performance ratings? If so, what were the results?

20 Additional Remarks:

21 Overall rating for this firm: O G A M U N/A

Printed Name of Evaluator

Signature of Evaluator Date

This questionnaire should be submitted to the US Forest Service via email to Marge Schafer at msschafer@fs.fed.us.